Corrective Action Plans

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Finding 1218279 (2023-007)
Material Weakness 2023
Responsible Parties: Erik Estill and Russell Raney Finding: Due to the passage of time, the turnover of staff, and the use of a third-party payroll provider, supporting documentation necessary to verify and document payroll transactions was not available, resulting in the inability to obtain suffici...
Responsible Parties: Erik Estill and Russell Raney Finding: Due to the passage of time, the turnover of staff, and the use of a third-party payroll provider, supporting documentation necessary to verify and document payroll transactions was not available, resulting in the inability to obtain sufficient, appropriate audit evidence related to these amounts. Corrective Action: The school (LEAD Academy) contracted with New Schools for Alabama (NSFA) during 2023 to handle all their finance and accounting needs. By the end of 2023, the school also transitioned all payroll services to New Schools for Alabama. Prior to 2024, a third-party vendor was handling/processing payroll for LEAD Academy. The upload file produced by the vendor was not accurately formatted, resulting in incorrect entries to some general ledger accounts, which required extensive corrections by NSFA to the FY 2023 financials. Many of these corrections involved federal ESSER funding, and the school was not able to identify specific individuals paid with ESSER funds or provide backup documentation. Additionally, procedures were not in place to maintain monthly payroll data (timesheets, leave balances, documentation of annual salaries) prior to 2024. All financial records are now maintained digitally, with the original documents residing at the school. Additionally, NSFA worked with existing staff regarding proper documentation and filing of financial records and helped establish a new filing system. In 2024, payroll processing for the school was transitioned to NSFA, utilizing the state approved accounting/payroll software. Monthly procedures are now in place for the submission, approval and documentation of all payroll transactions. Expected Completion Date: September 30, 2024
May 31, 2026 Hawaii State Rural Health Association Single Audit Report: Corrective Action Plan For the Year Ended December 31, 2023 Finding 2023-001 Management Response Management acknowledges the audit finding regarding the late submission of the audit, the data collection form, and the reporting p...
May 31, 2026 Hawaii State Rural Health Association Single Audit Report: Corrective Action Plan For the Year Ended December 31, 2023 Finding 2023-001 Management Response Management acknowledges the audit finding regarding the late submission of the audit, the data collection form, and the reporting package to the Federal Audit Clearinghouse. Corrective Action Plan After completion of the 2023 audit, we will be in a position to hire an auditor to perform the 2024 and 2025 audits at the same time, to get us back on a timely basis with the Uniform Guidance reporting requirements. Responsible Person: Summer K. Mochida-Meek, Executive Director Timeline: Corrective actions will be completed by September 30, 2026, for the year ended December 31, 2025. Summer K. Mochida-Meek Executive Director
Management acknowledges the need to strengthen system access controls and will review existing user roles and permissions, implement more restrictive controls over prior-period postings and establish periodic reviews of user access rights.
Management acknowledges the need to strengthen system access controls and will review existing user roles and permissions, implement more restrictive controls over prior-period postings and establish periodic reviews of user access rights.
Management acknowledges the need to evaluate the current check signing and disbursement authorization structure and will consider incorporating governance-level participation and tiered approval thresholds to strengthen oversight.
Management acknowledges the need to evaluate the current check signing and disbursement authorization structure and will consider incorporating governance-level participation and tiered approval thresholds to strengthen oversight.
Management acknowledges the need to strengthen internal controls over the calculation and reporting of TCDRS contributions. The District will implement enhanced review procedures to ensure consistency in the definition and application of eligible compensation and will improve reconciliation processe...
Management acknowledges the need to strengthen internal controls over the calculation and reporting of TCDRS contributions. The District will implement enhanced review procedures to ensure consistency in the definition and application of eligible compensation and will improve reconciliation processes between payroll records and TCDRS reporting.
Management acknowledges the need to expand the current capacities of the finance team and improve the timeliness of monthly bank reconciliations. The District is in the process of recruiting additional experienced and qualified personnel and implementing procedures to support more timely completion ...
Management acknowledges the need to expand the current capacities of the finance team and improve the timeliness of monthly bank reconciliations. The District is in the process of recruiting additional experienced and qualified personnel and implementing procedures to support more timely completion and review of monthly reconciliations.
Management acknowledges the need to strengthen internal controls surrounding the use of District credit cards. In 2024, the District implemented a requirement for the Harbor Master to review all credit card transactions prior to fulfillment of the combined credit card bill. Management is currently e...
Management acknowledges the need to strengthen internal controls surrounding the use of District credit cards. In 2024, the District implemented a requirement for the Harbor Master to review all credit card transactions prior to fulfillment of the combined credit card bill. Management is currently evaluating the form and function of a formalized credit card use agreement and related monitoring procedures.
Management acknowledges the need to expand the current capacities of the finance team and is in the process of recruiting additional experienced and qualified personnel. To assist with immediate reporting and compliance needs, the District continues to utilize external consultants to provide assista...
Management acknowledges the need to expand the current capacities of the finance team and is in the process of recruiting additional experienced and qualified personnel. To assist with immediate reporting and compliance needs, the District continues to utilize external consultants to provide assistance with grant programs and related accounting procedures.
Person(s) Responsible for the Corrective Action: April Samuels, VP of Finance Corrective Action Plan: Implement monthly reconciliation between PHDC and DHCD to identify and resolve any discrepancies in real time. Anticipated Completion Date: June 30, 2026
Person(s) Responsible for the Corrective Action: April Samuels, VP of Finance Corrective Action Plan: Implement monthly reconciliation between PHDC and DHCD to identify and resolve any discrepancies in real time. Anticipated Completion Date: June 30, 2026
Person(s) Responsible for the Corrective Action: April Samuels, VP of Finance Corrective Action Plan: Implement monthly reconciliation between PHDC and DHCD to identify and resolve any discrepancies in real time. Anticipated Completion Date: June 30, 2026
Person(s) Responsible for the Corrective Action: April Samuels, VP of Finance Corrective Action Plan: Implement monthly reconciliation between PHDC and DHCD to identify and resolve any discrepancies in real time. Anticipated Completion Date: June 30, 2026
The agency has created new policies and implemented fail saifs, including board involvement, to ensure the deadlines for all required filing are met. Person(s) Responsible: Claire Versaw, CFO Timing for Implementation: Currently in place as of 7/1/2024
The agency has created new policies and implemented fail saifs, including board involvement, to ensure the deadlines for all required filing are met. Person(s) Responsible: Claire Versaw, CFO Timing for Implementation: Currently in place as of 7/1/2024
As of the 2024-2025 fiscal year, the agency has created a sustainable cost allocation process that will be in place moving forward. New policies were created, including a system for analysis of allocations throughout the year. Person(s) Responsible: Claire Versaw, CFO Timing for Implementation: Curr...
As of the 2024-2025 fiscal year, the agency has created a sustainable cost allocation process that will be in place moving forward. New policies were created, including a system for analysis of allocations throughout the year. Person(s) Responsible: Claire Versaw, CFO Timing for Implementation: Currently in place as of 7/1/2024
LARS will develop and adopt a written cost allocation policy that governs the distribution of shared costs across funding sources. The policy will include the following: • An enumeration of permissible allocation bases, which may include client counts by program, usage logs, program participation da...
LARS will develop and adopt a written cost allocation policy that governs the distribution of shared costs across funding sources. The policy will include the following: • An enumeration of permissible allocation bases, which may include client counts by program, usage logs, program participation data, square footage, or other equitable measures that reflect the relative benefit received by each program • A prohibition on allocating costs based on funding availability, grant end dates, or spend-down considerations • A requirement that all shared cost allocations be supported by contemporaneous documentation identifying the allocation base used, the calculation applied, and the period covered • A requirement for supervisory review and approval of all shared cost allocations prior to recording in the accounting system • Consistent application of the chosen allocation methodology across all periods and funding sources
LARS has updated its procurement policies and procedures to reflect current 2 CFR Part 200 requirements, including the following: • The updated policy defines micro-purchase thresholds in accordance with current Uniform Guidance standards and requires that micro-purchases be distributed equitably am...
LARS has updated its procurement policies and procedures to reflect current 2 CFR Part 200 requirements, including the following: • The updated policy defines micro-purchase thresholds in accordance with current Uniform Guidance standards and requires that micro-purchases be distributed equitably among qualified vendors to the extent practicable • A simple price reasonableness documentation requirement has been added for micro-purchases, requiring staff to note the basis for determining a cost is reasonable (e.g., comparison to a prior invoice, market price check, or vendor quote) • A SAM.gov vendor verification step has been incorporated into the procurement process. Staff are required to check SAM.gov prior to making a purchase from a new vendor and to document the result. Verification results are retained in the procurement file
LARS has implemented the following controls to address each element of this finding: HUD CoC Match Tracking: A grant-level match tracking schedule has been established for the CoC program. The schedule documents required match amounts, eligible match contributions, and cumulative match-to-date, and ...
LARS has implemented the following controls to address each element of this finding: HUD CoC Match Tracking: A grant-level match tracking schedule has been established for the CoC program. The schedule documents required match amounts, eligible match contributions, and cumulative match-to-date, and is updated at each reporting period. The Finance Director reviews the schedule prior to each drawdown and at fiscal year-end. Administrative Cost Limitation Monitoring: Written policies and procedures have been updated to include a procedure for monitoring the HUD CoC administrative cost limitation. The Finance Director calculates the limitation at the beginning of each grant year and monitors actual administrative costs on a quarterly basis. Grant Cutoff Procedures: A written grant financial management policy has been adopted that establishes cutoff procedures for recording expenditures within applicable grant performance periods. The accounting system has been configured to flag transactions with dates outside an active grant period for Finance Director review prior to posting. SEFA Preparation and Review: A formal SEFA preparation procedure has been implemented that requires: • A reconciliation of SEFA amounts to the general ledger and underlying grant records • A documented review of all grants and funding sources including state and local grants to determine proper SEFA inclusion and reporting treatment
The Organization has agreed to the recommendation that all necessary efforts be taken to ensure the timely submission of the audit, Data Collection Form, and reporting package. Sufficient internal controls will be designed and implemented to detect and prevent errors in reports and within the accoun...
The Organization has agreed to the recommendation that all necessary efforts be taken to ensure the timely submission of the audit, Data Collection Form, and reporting package. Sufficient internal controls will be designed and implemented to detect and prevent errors in reports and within the accounting system and to ensure that the audit, Data Collection form, and reports are submitted timely.
The Organization has agreed to the recommendation to maintain appropriately trained and experienced personnel and has hired a new Director of Finance. This will ensure that the accounting processes and internal controls over Federal Reporting will be functioning properly.
The Organization has agreed to the recommendation to maintain appropriately trained and experienced personnel and has hired a new Director of Finance. This will ensure that the accounting processes and internal controls over Federal Reporting will be functioning properly.
Condition: Due to a lack of effectively designed and implemented controls to ensure compliance with allowable cost principles, management requested reimbursement based upon employment contract agreements rather than actual payroll costs incurred for the individuals working under the grant. Planned C...
Condition: Due to a lack of effectively designed and implemented controls to ensure compliance with allowable cost principles, management requested reimbursement based upon employment contract agreements rather than actual payroll costs incurred for the individuals working under the grant. Planned Corrective Action: The organization will implement internal controls to ensure expenditure is allowed in accordance with 2 CFR 200 Subpart E. Costs must be necessary, reasonable, and allocable. Contact person responsible for corrective action: Charles Berry (CFO) Anticipated Completion Date: 06/30/2026
Condition: A lack of effectively designed and implemented internal controls over the accounting records resulted in material entries identified and recorded during the 2023 financial statement audit of the Organization. Additionally, as the result of a lack of effectively designed and implemented co...
Condition: A lack of effectively designed and implemented internal controls over the accounting records resulted in material entries identified and recorded during the 2023 financial statement audit of the Organization. Additionally, as the result of a lack of effectively designed and implemented controls over financial and performance reporting for the Health Center Program cluster grants, inaccurate performance data and the Federal share of expenditures were submitted to HRSA. Planned Corrective Action: The organization will implement internal controls to prepare and review accurate reconciliations with supporting information over all accounting cycles in a timely manner. Contact person responsible for corrective action: Charles Berry (CFO) Anticipated Completion Date: 9/30/2026
Condition: The Organization maintains and tracks Federal expenditures incurred for the year in totality; however, it does not maintain adequate records to track the costs applied to each individual drawdown made throughout the year. Without this linkage, the timeliness between drawdown and either wh...
Condition: The Organization maintains and tracks Federal expenditures incurred for the year in totality; however, it does not maintain adequate records to track the costs applied to each individual drawdown made throughout the year. Without this linkage, the timeliness between drawdown and either when the expenditures for goods and services were incurred or when the disbursement occurred in relation to the drawdown cannot be validated. Planned Corrective Action: The organization will implement controls to ensure cash management and allowability compliance areas are addressed by linking cash drawdowns to Federal expenditures. Contact person responsible for corrective action: Charles Berry (CFO) Anticipated Completion Date: 9/30/2026
Condition: The Organization lacked sufficient internal controls to ensure sliding fee discount applications were on file and included all of the necessary information regarding family size and income to support discount determinations made. Further, controls were not sufficient to ensure the correct...
Condition: The Organization lacked sufficient internal controls to ensure sliding fee discount applications were on file and included all of the necessary information regarding family size and income to support discount determinations made. Further, controls were not sufficient to ensure the correct sliding fee discount was applied. Planned Corrective Action: The organization will implement controls to ensure sliding fee applications are maintained and sliding fee adjustments are based on correct family income and resident size. Contact person responsible for corrective action: Charles Berry (CFO) Anticipated Completion Date: 6/30/2026
Finding 2023-001 – Special Education Cluster – AL No.’s 84.027 & 84.173 Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Programs Criteria: The Period of Availabili...
Finding 2023-001 – Special Education Cluster – AL No.’s 84.027 & 84.173 Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Programs Criteria: The Period of Availability for the SPED PL 94-142 Grant was September 22, 2022 through September 30, 2024. Condition: During our test of controls over compliance it was noted that there are expenditures charged to the SPED PL 94-142 Grant (September 22, 2022 through September 30, 2024) for services outside of the period of performance as set forth by the Massachusetts Department of Elementary and Secondary Education. Context: During our test of expenditures and review of the general ledger against the SPED PL 94-142 Grant as it is related to compliance it was noted that 8 expenditures charged to the grant had service periods that were completely or partially for services prior to the grant start date of September 22, 2022 and thus would be outside the period of performance and thus would not be allowable costs. Effect: The School Department was not in compliance with the period of performance requirement as set forth by the Massachusetts Department of Elementary and Secondary Education. Questioned Costs: Questioned costs for the expenditures charged to the grant whose service period was completely or partially for services prior to the grant start date of September 22, 2022 was $31,948.58. Cause: A journal entry to charge costs to the grant included invoices that were outside of the grant award start. Recommendation: We recommend the School Department follow procedures to ensure that expenditures charged to the grant are within the period of performance as set forth by the Massachusetts Department of Elementary and Secondary Education. Responsible for Corrective Plan: Kathleen Grant Estimated Completion Date: Immediately Action Taken: Updated our procedures to ensure that expenditures charged to grants are within the period of performance as set forth by the Massachusetts Department of Elementary and Secondary Education.
As noted in the findings of the Single Audit Report, there was a delay in completing the annual audit and therefore the data collection form was unable to be completed timely. Management is currently getting all outstanding audits completed and up to date and subsequently the data collection forms w...
As noted in the findings of the Single Audit Report, there was a delay in completing the annual audit and therefore the data collection form was unable to be completed timely. Management is currently getting all outstanding audits completed and up to date and subsequently the data collection forms will be submitted.
Views of Responsible Officials and Planned Corrective Actions: LHCA's methodology for qualifying laboratory and affiliated organization expenses as industry in-kind contribution was developed in direct consultation with FAS program officials in June 2023. As documented in LHCA's written summary of t...
Views of Responsible Officials and Planned Corrective Actions: LHCA's methodology for qualifying laboratory and affiliated organization expenses as industry in-kind contribution was developed in direct consultation with FAS program officials in June 2023. As documented in LHCA's written summary of that meeting, transmitted to senior FAS program and operations officials including the FMD program officer and acknowledged without objection, FAS validated the eligibility of research, marketing, policy, and technical expenses funded through industry funds, focused on target markets, and connected to UES activities. LHCA was acting on direct FAS guidance, not making unsupported determinations, and that documentation is available for the auditor's review. The revenue figures that appeared in LHCA's contribution documentation served as an allocation methodology, a proportional basis for determining what share of multi-purpose expenses relates to export promotion, not as the contribution itself. The actual contribution claimed consisted of underlying expenses allocated using that methodology. LHCA acknowledges that this methodology was not clearly labeled in the documentation provided to auditors, and will revise its documentation format to clearly distinguish the allocation calculation from the contribution amount claimed, ensuring the two are not conflated in future reviews. LHCA will formalize its contribution tracking procedures with a written policy document that defines eligible activities consistent with FAS guidance, specifies the allocation methodology and its basis, and requires that all claimed contribution be supported by verifiable expense documentation consistent with the hierarchy established in FMD §1484.33(f) and the cost principles in 2 CFR Part 200 Subpart E. A documented review and approval process will be implemented to ensure contribution amounts are accurate, allowable, and properly supported prior to submission.
Views of Responsible Officials and Planned Corrective Actions: LHCA acknowledges that in two instances procurement documentation was administratively incomplete. In both cases the underlying competitive process was sound, vendors were evaluated, the appropriate vendor was selected, and the executed ...
Views of Responsible Officials and Planned Corrective Actions: LHCA acknowledges that in two instances procurement documentation was administratively incomplete. In both cases the underlying competitive process was sound, vendors were evaluated, the appropriate vendor was selected, and the executed contracts reflect those outcomes. No questioned costs were identified. In the first instance, a completed evaluation matrix existed with vendor scoring but did not include a formal notation confirming the award conclusion. LHCA operates in a fully electronic environment where wet signatures are not standard practice. Going forward, documentation systems are in place so that explicit award conclusion notation will be included in the vendor file to make the selection decision self-evident to any reviewer without requiring supplemental explanation.In the second instance, complete procurement documentation existed at the time of the audit but was not delivered to auditors in a timely manner due to staff turnover. This was a document retrieval issue, not a documentation gap. LHCA has addressed this by centralizing all procurement documentation in a shared Google Drive repository that is immediately accessible regardless of staff changes, and by designating a dedicated audit liaison responsible for maintaining and producing all procurement files on request. Going forward, LHCA will incorporate a conflict-of-interest representation clause into all contractor agreements, including the Meat Institute management agreement, effective with the next contract cycle. Annual execution of each contract will serve as the annual conflict of interest certification required under 2 CFR §200.318(c) and LHCA's contracting guidelines, eliminating the need for a separate certification process outside of Executive Board officers involved in procurement. Regarding the market representative relationships. LHCA's market representative relationships were competitively awarded at inception, and are maintained through annual performance evaluation consistent with MAP §1485.29(d)(5), which explicitly replaces periodic re-competition with annual performance evaluation for the life of the relationship. Where a market representative engaged under MAP takes on additional related work funded under other programs such as FMD, the regulatory framework supports an approach other than a new competitive RFP. MAP §1485.29(d)(5) establishes that market representative relationships are not subject to periodic re-competition by virtue of their specialized and relational nature. FMD §1484.35 requires documented price reasonableness but does not prescribe the specific mechanism. 2 CFR §200.320, which applies to both programs by incorporation, recognizes that noncompetitive procurement is appropriate where only one source is reasonably available. Taken together, these provisions support the conclusion that where an existing market representative is the only practicable source for incremental related work — by virtue of their established relationships, market knowledge, commodity expertise, and program continuity — a formal proposal-based review process satisfies the regulatory intent without requiring a competitive process that would produce no meaningful competition. LHCA therefore requires the market representative to submit a formal written proposal for any expanded scope, with deliverables, timelines, and line-item costs sufficient to support a documented price reasonableness analysis. A contract amendment is executed only upon a determination that the proposed scope and cost represent reasonable value. This satisfies the regulatory intent of MAP §1485.29(d)(5), FMD §1484.35, and 2 CFR §200.320 without requiring a competitive process contrary to program interests. LHCA will incorporate this procedure explicitly into its contracting guidelines to ensure consistent application and clear documentation of the policy basis going forward.
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